Why I’ve Been Prescribing Psychiatric Medication For 47+ Years

In 1968 the police brought a very tall man to the emergency department of a large urban hospital. I quickly learned the man had two PhD’s, one in literature and one in Library Sciences and he was employed as the chief librarian of an important Canadian Library. He was also manic. He could not sit still; he could not stop talking. What spewed from his mouth was a fascinating, pressured, endless run-on sentence of literary quotations, interpretations, criticisms, philosophical observations, and trivia.

The emergency department was designed as an oval, so it was possible to walk the corridor in a continuous circle of approximately 200 feet. This we did. I kept pace as he strode, talked, ranted, and raved, around and around that oval. I carried with me a glass of water and a pocket of tablets in my little white intern’s jacket. Every second or third circuit when he paused briefly to catch his breath I offered him a tablet and a sip of water. He accepted this, swallowed the tablet and continued his journey. I tried to remember some of what he said. I wish I had had a tape recorder handy. His observations roamed over much of English Literature and the history of western thought, in fragments, non sequiturs, creative associations and rhyming couplets.

The tablets in my pocket each contained 100 mg of Chlorpromazine. At four hundred milligrams he slowed at little. By the time I had given him 600 mg he was able to pause. And finally, at perhaps 800 mg and the passage of the better part of an hour, he could sit. The pressure in his speech diminished. He could now absorb his environment. I could now speak a little and he could now hear me.

In 1970 a dishevelled, tall bearded man was brought to a hospital by his family. They had found him, after months of searching, standing outside the Vancouver library in the rain. He had been sleeping rough; he was malnourished; he was not speaking. He was also a lawyer who had disappeared from his office practice, and his family, after announcing he was running for parliament, emptying his bank account, and then being briefly arrested for causing a disturbance. Now he was homeless, depressed, not communicating.

With clean clothes, a soft bed, good food, friendly nurses, and my anti-depressant medication, he was soon talking, more animated. But then he swung into a manic state: over-talking, grandiose, agitated, irritable, demanding. He wouldn’t sit in my office. He stood, paced, demanded I let him leave, ranted invective at my profession, my interpretations of reality, refused my pills. He stood and paced. I sat and listened. He didn’t leave, though the doors were never locked. His family let him know he needed to stay and accept treatment. The law society told him they would not reinstate him without treatment and a doctor’s note. Eventually he sat. Eventually we talked. He accepted my pills, my mood stabilizing medication, lithium. Eventually he was reunited with his family. Eventually he got his licence back. He became an outpatient. He re-established his practice, stayed on his medication, and asked me if I would like to play squash with him.

In 1978 parents brought a young man to see me. He was mute. He had stopped talking altogether. I had a white board in my office, and pads and pencils. The young man was willing to sit and respond to questions by writing out his answers. I found he dare not speak because if he did some tragic event would occur in the world. People would die. He knew this because it had happened. He had become angry, and had taken the Lord’s name in vain, and an earthquake had killed hundreds of people in the Middle East. He agreed to return to live with his parents, to eat and shower and sleep, and to swallow before bed each night the small tablet of Perphenazine I prescribed, and come to see me weekly. He came each week, and each week for an hour he wrote his answers on my white board, and when he tired of that, on the pad of paper I gave him. On his ninth visit I handed him the pad of paper. He put it aside and said, “We don’t need that anymore.”

On a lovely Sunday morning in June of 2008 my wife and I went for a walk. On the journey back I pondered ways to spend a leisurely afternoon. But then we found a frantic woman waiting for us in our parking lot. “John is psychotic again,” she said. John is her brother. An hour later I was in their father’s house. John was on the back porch smoking and pacing. I joined him there. He was agitated, mumbling half sentences in a semi-coherent fashion, some to himself, some to me. Changeable moods swept across him. His eyes would light up and he would tell himself and me that he was Jesus, and he had a mission to save the world, and that I would be forgiven, and then his mood would quickly darken, and he was evil, perhaps the devil himself, and that he should be punished, that he should destroy himself, and then just as quickly back to Jesus. I offered him a wafer of Zydis, a rapidly dissolving form of Olanzapine. He ignored this. His moods and thoughts continued to shift from Jesus to the devil, from good to evil, from a mission to save the world, to the need to destroy himself. I offered the wafer again, and this time he took it and let it dissolve in his mouth. A half hour later he was able to come into the house, and sit, and to sit quietly, and sip tea, and then to speak more rationally. Over the next few hours he became more coherent, better able to focus on the reality at hand. He would stay this night at his father’s, take another Zydis before bed, and they would come and see me in the morning.

It is now 2015. I am astonished to learn that there are people today, even some mental health professionals, who do not believe in the existence of mental illness, nor of the efficacy of psychiatric medications. I suspect that the closest brush they have had with insanity and pharmaceuticals is reading Jack Kerouac and William Burroughs in college, and the only knowledge they have of mental illness, and of the fate of the mentally ill before these medications were developed, has come from Hollywood, or the episode of Murdoch Mysteries I watched last night.

Thank you, Dr. Dawson for writing this article. What I find helpful is that you named the medications that you used. If we all become more familiar with the names of these medications and what conditions they are used for, then perhaps some of the ignorance that shrouds the whole topic of serious mental illness can be removed.
The patients you described were able to achieve wellness, but unfortunately that is not always the case for everyone. Statistics state that one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third are severely and permanently incapacitated. Only about 15% of all patients fully return to their pre-illness level of functioning.”
So the reality for many of us families, is that despite compliance with medication, our relatives remain quite disabled. Perhaps, they may not be as actively psychotic but they still have symptoms like anosognosia, lack of motivation, cognitive deficits. It is sometimes difficult to sort it all out. One big question I have is does the medication cause cognitive deficits? And why can a person be detached from reality on some issues, yet be perfectly lucid on other issues?

I would very much like to thank you for coming last month to our Home on the Hill “Ask the Doctor” session. Families expressed much appreciation and gratitude for the answers that you gave to their questions. As a family caregiver, and I believe that I speak for others, I appreciate getting answers about psychotic illnesses directly from the psychiatrist. Other professions may be helpful but it is only psychiatrists that have training in psychotic illnesses.
I really appreciated your insight about delusions and your answer to a father’s question about hearing voices. If we ever have reform regarding care for people with serious mental illness, the most effective modality would be collaboration between the family, their relative and the psychiatrist. Up to ninety per cent of people with mental illness live with their family, so a lot of people could be helped if this modality was a common practice. If we had more direct support, as you gave the other night, there would be less distress and homelessness.

I am a mother of a son with schizophrenia and agree with what Kathleen has said about the fear and frustrations of family members. I believe I should be able to see my son’s psychiatrist and tell him what I see on a daily basis. Perhaps the Doctor would try a new medication or have a better insight to the needs of my son. I realize the entire illness is extremely complicated. I wish I knew if there are any new medications about to come on the market..they need to be injectable..otherwise there is little hope of any compliance for so many people. I do appreciate all the valuable information I can read about..thank you Dr. Dawson.

Single dose therapy, even short term therapy, with medication is what these medications are tested and approved for. We see problems occurring when folks are kept on them for years, with little or no additional support.

I am not sure what profession you are from when you say “we see problems occurring when folks are kept on them for years, with little or no additional support”. Would you say the same about chemotherapy which has pretty profound side effects but can save lives. Similarly these drugs have side effects but do save lives. Apart from the family caregiver, and the psychiatrist who is monitoring the patient, I would agree with you there is little or no support.

ce harp, you would make this comment to a type one diabetic who depended on insulin to survive. person who have major mental illness likewise need appropriate medication on a long time basis. Thank you Dr. D for your service to those who have major mental illness and who need medical care. Clearly you have given appropriate time to individual patients to ensure that they have a chance at a reasonable life . Not the 15 minute appointment here. A lot of psychiatrist could learn from your patient care.

Dr. Dawson, as a family caregiver and regular watcher of Murdoch Mysteries, I would appreciate knowing which episode you were watching that you refer to in your last sentence.There are about 6 episodes of Murdoch Mysteries that feature characters with mental illness: 1. The episode about Charlotte, who had two other personalities; 2 & 3 Two episodes about David Kingsley, the young man with psychosis who believed himself to be Sherlock Holmes; 4. The episode about the woman with mute autism who created a streetscape in minute detail; 5. The episode about the “incurables”, women – including Charlotte – living in a mental assylum; 6. The episode about William’s phobia of butterflies (which I would say was a relatively mild phobia, not a severe mental illness, as it did not interfere with his functioning in daily life). Which of these episodes are you referring to?

Hello Patricia, I like Murdoch Mysteries and especially enjoy those moments they have “cameo” appearances by historical figures like Tesla, WCFields, or Edison, and Murdoch explains cutting edge science of the time, and the sly references to the future (e.g. Crabtree’s sliced bread is the best thing since….), to say nothing of highlighting the Suffrage movement. It was the “incurables episode” with the six ladies locked up in the very dark basement. I just happened to watch it the night before.
David Dawson

Dear Dr Dawson, your blog could have described my son perfectly! He has gone through most of your descriptions: mania, delusions of grandeur, malnourishment, religious delusions, many others. He wrote many many essays, including a whole 18000 word treatise on the Limbic System when he first became ill. He was trying to figure out why his brain didn’t work well any more. He was in mourning and driven to find a cure.

The only med to date that has helped him (and he has tried many) is Olanzopine. And dosage matters!

Thanks for your article. It is very helpful to hear from psychiatrists on serious mental illness.

It is imperative that the psychiatrist include the family caregiver as a partner in the patient’s treatment and care, and also that the family caregiver be educated to understand mental illnesses and know what he or she should be looking for. If the doctor unwilling to listen to and talk with the family caregiver, the caregiver and patient should find a better doctor! The medical protocol is to start with the least possible dosage that will quell the most distressing symptoms, then increase gradually only if necessary. A competent doctor will always monitor his or her patient on an ongoing basis to find the optimal dosage — just enough to quell symptoms that interfere with the ability to function in everyday life with the least possible side effects. Sometimes an individual has to try several medications before finding the optimal one at the optimal dosage, but a competent doctor does not do this on a “hit and miss” basis, but with carefully applied knowledge, A competent doctor will listen to a patient describe side effects and work with the patient to minimize or eliminate them. (For example, if weight gain is a side effect, it can be offset by a change to a healthier diet and increased physical activity. Side effects such as grogginess and dry mouth are often temporary and go away on their own) Also, a competent doctor will put the patient in touch with other psychotherapies and exercise regimens that may help reduce the need for medications. Many individuals can have the medication dosage reduced as time goes on and some can go off medications altogether and a competent doctor will monitor symptoms toward that goal. Medications often aren’t needed for a mild to moderate mental disorder and may be over prescribed for these, But for severe and persistent mental illnesses (eg. bipolar disorder, schizophrenia, severe clinical depression with psychosis) medications can literally save the person’s life by helping to prevent suicide and can make a difference between being totally unable to function socially to being able to have meaningful relationships, work and enjoy life. I am not a medical doctor myself, but am sharing this from what I have seen through many years as a family caregiver.

Patricia: It is not as easy for the care giver and the patient to find another doctor when the doctor and the patient have already formed a rapport that involves trust. When a patient is paranoid and may distrust family members, chances are he will have discussed these feelings already with the doctor. So then when the care giver wants to come with the patient to the doctor’s visit because there is something important that she needs to discuss, whatever she says may be challenged by the patient who will look to the doctor who he has learned to trust for support. For the doctor to be successful with the patient, trust is imperative. The patient needs to believe there is one person that he can trust without reservation. In these circumstances, I do not believe that it is possible for the patient to voluntarily leave the doctor.

The solution to these dilemmas, is for the doctor to be proactive in the first place. And discuss his/her policy right from the beginning before any patient/ doctor relationship begins. The doctor can explain to the patient that there will be times when he/she needs to hear from the care giver and that the meeting will take place in the presence of the patient. Or that the plan is for all three to first meet, and then the care giver leaves, so that the doctor and patient can meet in private.

The way things are right now with most family care givers being kept in the background by privacy legislation, or discrimination (as discussed in the 2007 Mood Disorder Society Report) the present patient/ doctor dyad does not recognize that 50 to 90 percent of people with mental illness live with their family care giver. It is not by choice necessarily that we house our ill relative but because we are in a severe housing crisis.

Hi Kathleen: I agree that the doctor needs to be proactive in including the family caregiver as a partner in treatment and care at the very beginning of the relationship between the doctor and the patient. I agree that trying to include the family caregiver after important decisions have already been made between the doctor and patient would be much more difficult and could lead to trust issues between the doctor and patient. In fact, some advocates believe that input from the caregiver should be part of the doctor’s very first assessment of the patient and I think that would be the ideal situation. After all, if a family caregiver has brought the patient to the hospital or doctor in the first place (or asked the police to), it doesn’t make sense for the doctor to assess the patient without interviewing the family caregiver to find out the patient’s behavior in the home or community that caused the caregiver to bring the patient to a doctor. I think the reason patients are so often discharged from hospital before they are ready is because the doctor has never seen their behaviors outside the structured environment of the hospital and has no idea what the family is contending with. If a doctor at a hospital refuses to listen to the family caregiver about readiness for discharge, I think it is important for family caregivers to realize that they can ask for a different doctor when they bring their family member to that hospital again for the inevitable readmission. It is also important for family caregivers to know that many hospitals have a family support worker whom they can talk to, who will advocate with the doctor and hospital on their behalf. I don’t wish to imply that any of this is easy for the already stressed-out caregiver. Speaking for myself, I have politely but firmly confronted doctors in hospitals and ACT teams on several occasions when I was convinced that a particular treatment plan (or lack thereof) was doing more harm than good. A few doctors were not interested in listening to me, but others did appreciate my input and changed the previous decision, so it is always worth a try. Meanwhile, of course, the family caregiver needs to keep the conversation going with their family member and establish as much trust as possible with a person who is suspicious and paranoid. None of this is easy, that’s for sure.

I agree with what you say. Especially the part about hospital professionals not having any knowledge of how the situation plays out at home. I firmly believe that all residents in psychiatry must have first hand experience in residing with a psychotic person. I agree with Vivian. These illnesses are complex. Not accessing important information from the caregiver simply leads to an incomplete assessment. But just had a recent experience in Emerg. 5 hour wait to see the one doctor at the local hospital. Not even the volunteer greeters were friendly it was so busy. Not exactly the place for social change to happen. Also another care giver communicated to me that the family peer support in the hospital where her son was was patronizing and dismissive. There are times when I think we are light years away from the change that would make it a system that would be more helpful to patient and family. The fact that most family care givers are female and our average age is 61 suggests that gender and age have something to do with resistance to change.

I think that the biggest hurdle to change is that policy makers are not really accepting the very nature of serious mental illness as a medical condition that will not be stabilized without proper medication. Time, expertise and patience are required. Policy makers (the ones that organize and allocate the money) think along very unscientific lines and indeed often pretend that serious mental illness is something that can be cured with fresh air and sunshine, with a big dollop of hope, a job and a home. This does a great disservice to those that have a significant diagnosis. It is torture for everyone concerned when access to real help is not available. Dr. Dawson knows the difference between mental health and illness and sets about doing something about it. Thank heavens someone out there knows that mental illness is just that.